Medicare ABN, codes and modifiers for Chiropractic
in plain, simple English

Certainly you need to consult with the Medicare Website for the particulars, but here is a simple rendering of what the new ABN is all about:

The new ABN form will be mandatory for all Medicare Providers beginning September 1, 2008.

ABN: Advance Beneficiary Notice is designed to protect the Medicare provider as well as the patient. If the patient signs the ABN form and we send a claim to Medicare and they, for any reason, refuse to pay, we can then turn to the patient for payment. We have a written and signed document protecting our financial rights to payment. It is also good for the patient because he/she is fully informed on what they can expect from us and from Medicare as far as financials are concerned.

We have 2 forms for you to download on this page. These particular forms are modified so you can add your Practice name, address and telephone number (required on the ABN) yet they are fully compliant and originated from the ChiroCode Institute, Phoenix, Arizona. You can find the ChiroCode link on the Resources page.

One form is for the Medicare (only) patient to sign when they come in for the first time to receive X-Rays and Exam. Medicare will not cover these services and the patient needs to be informed of that. Whatever your prices are, do not write anything on the form that will be seen as a “discount” or any form of inducement over $10.00 to get them in the office as a patient. Medicare is very clear that if there is any evidence of inducement over the value of $10.00, then the practitioner is committing insurance fraud. We have some DOCs that do offer coupon discounts, but because of the Medicare rule, they are very careful NOT to offer these discounts to Medicare patients.

Fill in the patient’s name and you can use any inter-office ID number in the identification number space.

In the SERVICE box, write down "X-Ray" and "Exam" and maybe even "Therapy." Under REASON, you can state "Not covered" or "Non covered service." You need to put in an estimated cost. Only one cost needs to be put in that box, as it can cover all of the services listed. Also, the words “Non covered service” only needs to be listed once as it will apply to all of the services listed.

OPTIONS

Most patients will go for Option #1. They want the service and they want it billed to Medicare and they understand that if Medicare does not pay, they are liable for payment.

Option #2: They want the service, but do not bill Medicare. We can bill another insurance company if they have another Primary carrier, or at that point they become a Cash Case.

Option #3 says they are not interested in being one of your patients! They do not want treatment, and they will not pay for it anyway.


What to do when they choose option #1:

Find out if they have secondary or supplemental insurance. Supplemental insurance will pick up the patient’s co-pay, whereas secondary insurance might pay for some of the services that Medicare does not pay, as well as the deductible.

You can follow this procedure even if they do not have secondary, so just to keep things simple: Bill everything that DOC does. Bill it to Medicare even if Medicare does not pay, because the patient may have a secondary insurance that might pay for some of the non-covered services.

Medicare covers the CMT codes 98940, 98941 and 98942. Always add the AT modifier, which denotes Active Treatment. This is all that Medicare covers!

When DOC does the first visit, you can, as an example, bill 72010, which is Full Spine X-Ray. X-Ray and Exam is not covered by Medicare, so you will add the GY modifier, which means “non covered service.” If DOC does an adjustment on the same visit as the exam, then bill the exam, 99203, with a 25 modifier as well as the GY modifier. If DOC does not do an adjustment, then bill 99203 GY.

Added note: Further down the road, if DOC does therapy, bill it with a GP as well as a GY modifier. GP means “therapy.” So it would be: 97104 GP GY

Have the patient sign and date the form, and if their handwriting is illegible, have them print their name also. Make a copy and give it to them. Put your copy in the patient's file.

The second form is for Maintenance care. This is after they have gotten many treatments and are as good as they are going to get and want to continue receiving the adjustments to keep them from reverting back to the uncomfortable state they were in before treatments started. Have them sign this form before maintenance starts.

Medicare will not pay for maintenance care, but once again, if the patient has a good secondary insurance, the secondary may pay. This form is the same as the first one, just modified to fit the Maintenance situation.

If they choose option #1, we will continue to bill Medicare, but will not add the AT modifier. If a chiropractic adjustment code does not have the AT modifier on it, that means it is Maintenance care. We can bill out everything that DOC does, and if they have a good secondary insurance carrier, we may get some payment, but not from Medicare.

Do not put the GY modifier on the CMT codes. Leave off the AT modifier, and put a GA modifier instead. GA means that there is a signed ABN form on file.

If they choose option #2, then we do not have to bill Medicare. This form will be good for one year from the date signed. If after one year the patient is still coming in and is getting maintenance care, he/she will need to sign another form.

Once again, have them sign and date the form, give them a copy and file yours in the patient’s file.

If you have any questions, feel FREE to email or call me, Deb Tru, for further clarification and simplification. debtru@tmedbilling.com

You can find the forms at: http://tmedbilling.com/NEWS.html

http://tmedbilling.com/NEWS.html